In this article I will examine the relationship between diagnosis, contracting, and treatment planning concepts used by TA psychotherapists; and show how the contact with a client is fundamental to these ways of working.
Eric Berne, the father of Transactional Analysis, in a radical departure from his psychoanalytical background, pioneered openness and honesty in the treatment process, inviting patients into an equal partnership in their healing. Since then, two main guiding principles of TA psychotherapy have become the contractual method, and open communication, with the main implications being that both the therapist and client share responsibility in the treatment planning. However, Berne (1966) also said that the 'real doctor must be orientated primarily towards curing his patients; and be able to plan the treatment, so that at each phase s/he knows what s/he is doing and why! With my own clients, I intuitively begin assessing and diagnosing, albeit tentatively, as we make first contact. Diagnosis is defined by Rycroft (1972) as
"The art of attaching labels to illnesses, of deducing the nature of the illness from the signs and symptoms presented by the patient."
In my very first moments with a client, I begin using the fundamental ego-state diagnostic techniques Berne talks of in TA in Psychotherapy (1961) He provides four levels of diagnosing ego states:
Berne cautions that, for a complete diagnosis, all of these four levels must be present. He stresses the importance of intuition as well as observations in this process. Therefore, Berne made a major contribution to the diagnostic field with these tools for identifying and labeling human experience and behaviour.
Other diagnostic models marry the contact element of the relationship with the making of a diagnosis contract, in this sense, refers to the quality of the transactions between people, and is defined by Richard Erskine (1993) as
"the full awareness of both one's self and the other as exemplified in and authentic and sensitive encounter."
In Paul Ware's 'Personality Adaptations' (1983), the therapist is given a diagnostic method to assess an effective way to make initial contact, and a likely treatment direction. Therefore, a structure can be provided for treatment planning, and decisions made about appropriate interventions, all guided by contact with the client. With models based upon contact, diagnostic procedures are unlikely to substitute for a healing relationship. Indeed, the over- reliance on a diagnosis can create false certainties and possibly lead to 'cook book' treatment planning.
"We can never find ourselves or any other person through diagnosis ... These methods break up the self, fail to recognize the emerging powers of choice, promise and the sudden new awareness and discoveries and creations of a unique, growing person." (Moustakas 1967)
The above quotation illustrates that diagnosis may not be fluid enough to serve the client well. By this I mean that as the 'self' of the client emerges within the therapy relationship, the therapist's diagnosis should follow along behind. The diagnosis then can be used to facilitate the emergence of self rather than 'break' it up.
lan Stewart (1989) indicates frequent review of diagnosis as being integral to treatment planning, and that methods of diagnosis give a wide range of information about a client, which in rum can give detailed guidance to the treatment plan. In his 'TA Counselling In Action'(1989) Stewart defines a treatment plan as an informed choice of procedures.
"Decided upon in the light of psychodiagnosis, and systematically followed through in the service of the contract goal."
He maintains that the experience suggests certain methods of treatment can be effective with clients showing certain signs and symptoms.
In the Treatment Triangle model, Stewart has proved a clear indication of the three-way interplay between contract, diagnosis, and treatment direction (see Fig. A) He talks of the informed choice of interventions facilitating a client in achieving their contract.
I am aware of two interlinked levels of treatment planning in my work. The first is what Clarkson(1992) calls the microscopic perspective; observing subtle signs and symptoms that indicate such things as a client's stroking diet, and possible early script decisions. I am also taking this one stage further in hypothesizing what new stroking they may need, what new permissions they need etc. The importance of this skill in 'collecting and evaluating data' (Berne 1966) should not be underestimated, as the first few minutes of a session contain many of the major themes of a person's therapy. Therefore, diagnostic ability at this point is crucial to the overall treatment plan. As these, microscopic' skills are being used in all contact with a client, there is a constant feedback process into a therapist' thinking on the treatment sequence.
The second perspective on treatment planning is macroscopic. Many writers (e.g. Woollams and Brown 1978: Clarkson 1992) have offered treatment plans with typical stages through which a client may move in therapy. Most authors agree that treatment direction is rarely a logical step-by-step movement through a plan; rather that reviewing stages becomes an integral and an instinctive part of the therapist's thinking on how to proceed. Clarkson (1992) considers treatment planning to be an aid to clarity in the therapy process, rather than as a clinical exactitude. She describes this as
"the unfolding of a journey into an interior for which the psychotherapist indeed does, not have a map, but brings map making skills."
Therefore, the therapist can use their previous knowledge of typical treatment stages, and use this creatively within the relationship as it develops. The contracting within the treatment plan is very specific to TA psychotherapy. In 1966 Berne defined a contract as
"an explicit bilateral commitment to a well-defined course of action."
Contracts are an agreement between the therapist and client that outline goals, stages and conditions of treatment. They are vital in making intentions and expectations between people explicit, and important in engaging the client fully in the treatment process.
Before negotiating a treatment contract Stewart sees a stage of assessment and diagnosis. In this period he contends that only 'soft' exploratory contracts should be taken. Then, after the stage has been set for change (including closing escape hatches-see Stewart 1989) a treatment contract- a 'hard' contract, can be formulated.
In other treatment plan models e.g. Woollams and Brown-1978; the focus begins with the client's motivation and awareness before moving towards a hard treatment contract. I particularly like Clarkson's first stage as being the, establishment of a working relationship'. She talks of the contracting stage being achieved when both client and therapist have used this working relationship to establish clear well-defined goals that set the treatment focus. Whilst using treatment contracts in my work I am sure to acknowledge that these contracts may be adapted or changed to suit my client's needs or aims. Again, this means that contracting becomes an ongoing process within the therapy relationship.
In the contracting process the therapist needs to be carefully guided by diagnosis. A contract goal will consist of new behaviours, and needs to represent a move out of the negative aspects of a client's script or life plan, rather than reinforce it. Therefore the therapist will use their knowledge of the client's history (script analysis), and ego state diagnosis. This knowledge also comes to the fore when considering a sequence in which to invite clients to make contracts for script change. For example, identifying a compound script belief system such as "It's only OK for me to be close to people as long as I please them", would mean inviting the client to take unconditional permission to be close to others, which may be the defense.
"Contracting within psychotherapy is like the substructure of a building: it cannot be seen, but it undergirds and supports all that is above ground." (Erskine 1993)
For me, this quotation sums up the relative importance of contact and the other elements 1 have discussed. Contact with a client is, fundamental to the effectiveness of these other elements. In her discussion of meta-perspectives concerning diagnosis (1992) Clarkson differentiates between the left hemisphere (of the brain) diagnostic, treatment planning skills of the therapist; and the right-hemisphere emphasizing the melody of the relationship! She sees the real goal of psychotherapy as:
"an orgasmic flow between the two positions, using the best of both, at the expense of neither, in rhythm with the appropriateness of the task, and the demands of the I-though encounter!"
In order to represent these themes of the flow between the relationship and an analytical perspectives; and the interwoven nature of these analytical elements; I present an integrated model (see fig B) based on Stewart's Treatment Triangle.
In the Process Pyramid I have added in the element of contact to diagnosis, contract, and treatment direction. As can be seen all the elements link up with each other, with contact placed at the high point of the pyramid. The model is designed to illustrate that contact with a client informs, and can be informed by, the other components on the base of the pyramid.
In conclusion, diagnosis, contracting and treatment planning are concepts and labels that essentially monitor, track and describe processes and experience . These processes are happening both intra-and inter-psychically in any relationship. In a therapeutic relationship, this monitoring and tracking will only be orientated towards 'cure', provided it is secondary to the relationship-between of the encounter-as it unfolds, rather than as an end in itself.
My thanks and love to my husband, Conrad for his invaluable proof-reading of this article. HAYLEY MARSHALL BA (Hons) I am an experienced counsellor / psychotherapist with a wealth of knowledge and skills based on my work in a busy GP Surgery, dealing with a wide variety of issues. In my private practice I work at the Manchester Institute for Psychotherapy, and in Stockport. For enquiries and appointments telephone 0161 285 8611